International Medical Graduate II

I hope by having this conversation with you I can share a unique perspective and, ultimately, contribute to improving the match process including for IMGs who can be strong applicants but face a different set of barriers.

The last post, opened up the topic of International Medical Graduates (IMGs) and a personal conversation I had with one that had yet to successfully match into ophthalmology.  I’d like to continue that thread today, highlighting some of the obstacles IMGs face in securing a training position.

As before, the italicized excerpts from this conversation are kept anonymous, but published with permission.

Reflecting on my last match experience; out of the 112 programs I applied to last year, I was offered only two interviews. Both from programs where I had connections. I find this surprising, especially after reading other applicants experiences online and comparing my application to theirs, and know how many invites they were offered.

According to NRMP data, only 5.6% of IMGs successfully matched in 2018 (versus 94.3% for US graduates). The odds are deflating, and the process costly – both in terms of time and finances.  It takes a IMG an average of three years to enter an ACGME residency program, with the following steps required to becoming an active physician: “confirm eligibility with ECFMG, obtain ECFMG certification (dependent on passing USMLE Step 1 and Step 2 examinations), obtain experience in the US health care system, apply for residency, complete residency, pass USMLE Step 3 examination, apply to state medical board for licensure, and finally receive license to practice medicine.”

Of course, each of these steps have fees.  As mentioned previously, it currently costs a IMG $4,500 just to sit for the USMLEs.  Additionally, like – and even more than – most other applicants, IMGs feel the need to apply broadly for residency positions: 

As I shopped for programs this match cycle, I ended up applying to almost all programs again. I applied broadly for three main reasons. First, the system incentives you to apply to more. Second, having had only two invites last year, I thought it would be unwise of me to apply for less. Third, I justified this to myself as a long-term investment and I am only losing money (me consoling myself for paying >$3,000 for the third time now just to apply to programs).”

Here are some of the other hurdles IMGs face:

 The visa sponsorship barrier – A few programs explicitly state that they don’t sponsor visas. Although I find it surprising that all of these programs have a “Non-discrimination Statement and Policy”, I totally respect the transparency regarding their visa policy.

According to the same 2018 NRMP data, the average USMLE Step 1 and 2 CK scores for matched US IMGs was 222 and 232, while it was 234 and 240 non-US IMGs, respectively.  This also suggests a bias over visa status.

Programs prestige and the IMG stigma – I was once told by a program director, who I approached after a panel discussion at the AAO, that he would love to have me for an interview, but went on to say he couldn’t, and this is because they have a unspoken policy against IMGs, as matching an IMG would make them look weak to other applicants. 

Internationals are a minority within the applicant pool for Ophthalmology – Unlike other specialties, like medicine for example, ophthalmology programs are not exposed to a large number of applications by IMGs, and therefore may not be used to reviewing it. I once got a rejection from an ophthalmology program I am interested in, and when I reached out, the feedback was they thought I consistently scored below average during my med school, which didn’t make sense. Turned out they read the passing scores on my med school transcript as my actual scores. Also, a GPA of 3.3/4 is not the same across every medical school across the world, and the concept of AOA or Gold Humanism award is not known to my med school, for example. So, comparing all applicants as apples to apples can be tricky.

The total number of IMGs participating in the ophthalmology match last year was 61, representing 9% of the applicant pool.  Within the NRMP, the Electronic Residency Application Service (ERAS) provides the option for programs to skip the Medical Student Performance Evaluations (MSPEs) of IMGs.

Flexibility is a double edge sword – Having my immediate family in [a foreign country] makes every state/city in the US equally attractive, and this gives me flexibility that not everyone has. At the same time, it makes it hard for me to make the case that I have strong ties to a specific city or location – which I feel programs value a lot and factor in the selection process. I try to be honest about this when I write a letter of interest to a program, but not sure how well that is perceived.

…………………………………

The residency application process is time consuming, costly and nerve wracking for every applicant.  There are very valid reasons for certain groups to feel disenfranchised or particularly vulnerable in the process, such as those with borderline board scores, are from DO programs or lower tier institutions, ethnic and gender related disparities, and many others. These two posts are not an attempt to minimize those issues, but to highlight another group that is often (at least in my limited, personal experience) even further marginalized.  I don’t have an immediate remedy for any of this, but I hope that discussing it and providing the perspective of one applicant can raise awareness. 

I’ll finish with an update. This conversation and blog post started in the fall of 2019, well before the match cycle ended. I was so thrilled in January to receive an email from this individual stating they had matched into an ophthalmology residency position. Below are some of their parting thoughts:

I am happy, I am elated and I am excited for this new chapter, and the longer the wait the greater the reward. When the chair of the department congratulated me on the match day he said “It took a while but it was worth the wait”. I couldn’t agree more. I think anyone who matched would say the same, so I am not sure how much more I can add to that. I do, however, have something to say about my experience not matching in the previous cycles that is maybe worth sharing with others.

Everyone applying to ophthalmology match or any match in general has challenges to overcome, and in my case being an IMG was one challenge. The challenge may vary but I believe it’s the attitude toward a challenge rather than the challenge itself is what really matters. Working on developing mental toughness and adopting a growth mindset is what helped me shape my attitude not when I matched, but when I didn’t, and kept me motivated to purse my goals. These are a few of the strategies that helped me:

–        There is no one-size-fits-all:

I am fortunate to have many friends and mentors who I met along the way and were very generous to support me and share their experiences with me. For them, I am eternally grateful. But what has worked for them isn’t necessarily what has worked for me. For example, the year I matched I wore a blue suit (it looked darker before buying it in the store!) which was against the “match guide” rule of wearing a dark navy or a dark gray suit. However, I still matched. This is not to say that blue suits are a significant factor to match (maybe it was for me!), but this is to say that everyone has a unique story.

–        Breaking out of the victim mentality

My father, who is a lawyer in [international country], told me once “I don’t know much about the medical training in the US, or what it takes to match into ophthalmology, but one thing I know is that it’s a country influenced by capitalism. You should bring more to the table than what you expect to take”. His advice opened my eyes and helped me break out of the victim mentality of saying that the system is biased against IMGs (which is at least partially true), and find excitement in adopting an entrepreneurial approach.

–        The very basic rule: take care of your body.

Eat healthy, exercise and sleep well. The simplest, yet most effective strategy (whenever I could afford it).

–        Surround yourself with those who believe in you.

I can’t stress this enough. Supporters of success are not very common encounters so keep them close. This is not to say that people who constantly remind you how extremely hard matching into ophthalmology is are bad people, in fact they are realist who rely on facts. But it’s important not to let these constant reminders put you down.

–        Good things take time

This is not a sprint, but a marathon. After speaking to other inspiring IMGs who matched into ophthalmology before me, one common theme stands out; time. They all spent a couple of years working hard before matching, and that’s the plan I had in mind. Being patient and planning my short- and intermediate-term goals accordingly helped me a lot.

–        Time is a luxury

Being able to continue to pursue ophthalmology after not matching is a privilege not everyone can afford. Some people have loans or other circumstances that would make it impossible to pursue something for a long time. That said, I had to make sacrifices myself to be able to afford such luxury. So make sure to know what you want, and rearrange you priorities accordingly. Nonetheless, I acknowledge and feel grateful for the privilege of time. 

–        It’s about the journey not the destination. 

As cheesy as this may sound, it’s very true. Numbers don’t lie; some applicants won’t match. I could have been one myself. What helped me live with this possibility is changing the definition of success by instead of saying I am successful only if I match, I tried to say I am successful as long as I am continuing to improve, learn and have an impact. Roosevelt said it better: “Do what you can, with what you havewhere you are”. At the end of the day, life is larger than a residency position. Although this is maybe obvious to others, I found myself too involved and had to remind myself of this from time to time.

–        At the end, it’s all about the people.

As my program director told me after the match; beyond the USMLE scores, the letters, the publications and what not, it goes down to connecting as a human. The reason why I chose ophthalmology in the first place, and the reason why I ranked my matched program as my top choice is the people. These are people I look up to and people I enjoy working along with. 

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